Nimble adaptations to sexual and reproductive health service provision to adolescents and young people in the early phase of the COVID-19 pandemic

Abstract Early in the COVID-19 pandemic, emerging evidence showed that the provision and use of a range of health services, including sexual and reproductive health (SRH) services, were affected. Otherwise, there was little evidence on whether and how they were adapted to maintain the access of different population groups, including adolescents. The study aims to provide an overview of adaptations to adolescent sexual and reproductive health (ASRH) services carried out during the early phases of the pandemic in low- and middle-income countries (LMICs). The Human Reproduction Program (HRP) at the World Health Organization (WHO) called upon WHO and United Nations Populations Fund (UNFPA) regional offices to reach out to organisations that provided ASRH services to submit analytic case studies using a short-form survey. The study team charted information from 36 case studies and performed a content analysis. Results show that the adaptations covered a wide array of SRH services that were provided to a diverse group of adolescents. Most adaptations focused on SRH education and access to contraception in comparison to other SRH services. Over half of the case studies included mental health services, most of which were not provided before the pandemic. The adaptations varied between being face-to-face, remote, digital, and non-digital. Most adaptations complemented a pre-existing service and were nimble, feasible, and acceptable to the targeted adolescents. Lessons learned from this study could be extrapolated into other humanitarian settings and rapid responses for future public health emergencies, provided that rigorous evaluation takes place.


Introduction
Adolescents and young people constitute a large part of the world's population, estimated at 1.8 billion, of which 1.3 billion are aged 10-19, and around 90% live in low-and middle-income countries (LMICs). 1 Since the International Conference on Population and Development (ICPD) in 1994, there has been global progress in many areas of adolescent sexual and reproductive health (ASRH). 2,3However, evidence from previous public health emergencies showed that adolescent health, including sexual and reproductive health (SRH), tended to be neglected, [4][5][6] and their access to SRH services was impacted, especially when resources were diverted to containment responses. 6,7Early in the course of the COVID-19 pandemic, according to a scoping review of evidence gathered in February 2021, access of adolescents to SRH services was affected, specifically access to contraception, menstrual health products, and anti-retroviral treatments (ARTs). 81][12][13][14] Furthermore, there have been reports that the challenges to access were more pronounced among underserved adolescents. 15s the international community became aware of the challenges that the pandemic might impose on access to services, several guidelines were issued to modify service delivery to mitigate restrictions enforced by the effects of the pandemic. 16For instance, in May and June 2020, the WHO published two documents about maintaining essential health services and communitybased care in the context of the COVID-19 pandemic, 17,18 and UNFPA published a supplemental technical brief titled Not on Pause: Responding to the sexual and reproductive health needs of adolescents in the context of the COVID-19 crisis. 19This technical brief set out recommended actions for the delivery of services, monitoring, and considerations for the transition towards restoration and recovery for each component of the Guttmacher-Lancet Commission's essential package of sexual and reproductive health and rights (SRHR) interventions for adolescents, in the context of COVID-19.
While service providers worked during the early phases of the pandemic to adapt SRH services for adolescents, at the time of this study, there was limited research on which SRH services were delivered during the pandemic, to which groups of adolescents, and how these programmes were adapted to maintain access of adolescents to SRH services.Our paper expands on the reports of initiatives from the Philippines, Zimbabwe, South Africa, and other countries in adapting SRH services delivered to adolescents [20][21][22] in terms of geographical scope, types of SRH services, and the groups of adolescents reached through nimble adaptations to SRH services by organisations during the early phases of the pandemic in LMICs.Our research question is: How did organisations from LMICs respond to the different SRH needs of adolescents during the early phase of the COVID-19 pandemic?

Data collection tool
The study team developed a simple analytic case study tool using a survey that included questions that were categorised into four sections.The first was a background section that explored the organisation's mandate and the SRH services that it provided to adolescents before the pandemic.The second section explored the adaptations made to the SRH services that were provided by the organisation to adolescents during the early phase of the pandemic.The third section explored the reasons behind carrying out these adaptations and how they were developed.The final section explored whether the adaptations were monitored.

Data collection procedures
The study team gathered case studies of adaptations by organisations to provide SRH services to adolescents in line with the recommendations made in the UNFPA technical brief. 19To gather these case studies, the HRP/WHO called upon WHO and UNFPA regional offices to identify organisations to submit case studies.Eligible responses had to satisfy two conditions: (i) the submitting organisation had to be from an LMIC and (ii) completeness and adherence to the tool format.There were no limits on the number of submitting organisations per country or region, the type of SRH service provided, or the targeted group of adolescents.Two independent researchers contacted the organisations, provided them with the study survey, and followed up with them to ensure proper reporting and completeness.As the pandemic rolled out differently in different countries, it was important to provide enough time for data collection to gather information about a wider variety of adaptations to SRH services in different contexts.Data collection started in April 2020 and was completed by December 2020.While the data collection period coincided with two waves of the COVID-19 pandemic, 23 particularly in Asia 24 and Africa, 25 the information shared was mostly *According to UNFPA, SRH commodities refer to SRH supplies, equipment, and kits that are core components of family planning, maternal and neonatal care, and STIs and HIV-related services.For example, they include contraceptives, family planning devices, pregnancy testing kits, delivery kits for use at home, midwife professional kits, condoms, and self-testing kits, among others. 9pecific to the first wave or directly after.Out of 40 case studies gathered by the team, three were excluded due to their incompleteness, and one was excluded due to a lack of adherence to the predetermined format.

Data abstraction
The study team abstracted the information using an abstraction sheet that included domains about characteristics of the organisations, types of SRH services provided before and during the early phase of the pandemic, adolescents and young people targeted by these services, adaptations used by these organisations to deliver these services, and whether they were face-toface, remote, digital, or non-digital, in addition to domains about the design, development, and monitoring of these adapted services during the early phase of the pandemic.

Data analysis and synthesis
Two researchers were involved in the analysis of the data and the synthesis of the results.They developed a framework of four sub-questions that were aligned with the research question to inform the data analysis and synthesis.These questions were: (1) Which SRH services were provided by the organisations in LMICs to adolescents during the pandemic?(2) Which adolescent groups were targeted by these services?(3) What were the adaptations used by the organisations to provide the SRH services to these adolescents?and (4) How were these adaptations developed, delivered, and monitored?The study team charted the data, reviewed the abstracted information, then performed a content analysis and a narrative synthesis of the abstracted data and presented the study findings in correspondence to the mentioned framework.

Supplementary data
The full set of case studies is available in the Medicus Mundi Bulletin entitled: Lessons learned from nimble adaptations to organisations' responses to the sexual and reproductive health (SRH) needs of adolescents in the context of the COVID-19 crisis.https://www.medicusmundi.ch/de/wissen-undlernen/reflexions-und-lernformen/who-case-studies/.

Ethics statement
Confirmation that this study was exempt from ethics committee approval was obtained before data collection began from the Research Protocol Review Panel of the World Health Organization's Department of Reproductive Health and Research, based on a standing exemption on the grounds that this was a public health activity that drew out managerial information from the service managers, plans and reports in the public arena and did not involve primary data collection from either the providers or the beneficiaries of such programmes.

Results
We provide an overview of the characteristics of the organisations, SRH programmes, and target audiences involved in the 36 case studies, in addition to the development, delivery, and monitoring of the adaptations used by the organisations to provide SRH services to adolescents and young people during the early phase of the pandemic.

Regions, countries, and organisations
The 36 case studies were from four different world regions, 16 countries, and 41 organisations.In many instances, there were multiple case studies per country, but each case study was unique and came from a different submitting organisation.Of these 36 case studies, 17 were from Africa, 16 were from Asia, one was from the Pacific region, and one was from Latin America.In addition, there was a global case study submitted by the International Planned Parenthood Federation (IPPF) that presented examples from its member associations.In Africa, the 17 case studies were from nine countries: Benin (n = 1), the Democratic Republic of Congo (DRC) (n = 1), Kenya (n = 2), Malawi (n = 1), Namibia (n = 1), Nigeria (n = 4), South Africa (n = 1), Uganda (n = 3), and Zimbabwe (n = 3).In Asia, the case studies were from five countries: India (n = 9), Laos (n = 1), Myanmar (n = 4), Nepal (n = 1), and the Philippines (n = 1).The three remaining case studies were from the Pacific region (Fiji), Latin America (Argentina), and finally, the global case study submitted by IPPF.In four of the case studies, responses were submitted by multiple organisations that collaborated in each case.Therefore, the total number of organisations (n = 41) is higher than the total number of case studies (n = 36).The submitting organisations were mostly non-governmental organisations (n = 29), in addition to United Nations agencies (n = 5), governmental sectors (n = 4), for-profit organisations (n = 2), and one academic institution.Detailed results appear in Table 1.

SRH programmes
The case studies covered adaptations to multiple SRH programmes that were provided to adolescents during the early phase of the pandemic.The majority of these programmes included: (i) SRH education, including comprehensive sexuality education (CSE) † programmes; (ii) access and referral to contraception services; (iii) access and referral to HIV care; (iv) menstrual health education; (v) access to safe abortion and/or postabortion care; (vi) access and referral to sexual and gender-based violence (SGBV) care; and (vii) distribution of SRH commodities.In addition, there was one case study that discussed adaptations to an HPV vaccination programme during the pandemic.The majority of the case studies discussed adaptations to SRH education programmes which included 22 case studies, of which five were CSE adaptations.Out of the 36 case studies, 16 reported adaptations related to multiple SRH services that were undertaken concurrently.Detailed results appear in Table 1.

Target audiences
The majority of the adaptations targeted adolescent girls, adolescent school students, and adolescents in nearby communities, and to a lesser extent, out-of-school adolescents, and adolescents living with HIV.The groups least mentioned were pregnant or married adolescents, adolescents living in rural or urban informal settings, adolescents with disabilities, and lesbian, gay, bisexual, transgender, queer, or other (LGBTQ+) adolescents.Detailed results appear in Table 2.

Development of adaptations to the SRH programmes
During the early phase of the pandemic, particularly its first wave, organisations reported that governments issued lockdown measures that included mobility restrictions or curfews and the avoidance of gatherings.Many public and private health services were completely or partially shut down.Similarly, schools and recreational facilities for young people were closed, and their services were discontinued.In many instances, adolescents and healthcare providers were impacted by the mobility restrictions, thus limiting access to SRH services.Therefore, organisations developed their adaptations primarily to mitigate the lack of access to SRH services due to the pandemic containment measures using remote, mostly digital approaches.The lockdown measures were imposed during different periods across the countries as the pandemic waves peaked and waned differently.In areas where lockdown measures were not yet imposed or did not mandate services' closure, in-person services were either adapted to be provided in compliance with COVID-19 safety protocols, or as a hybrid of in-person and remote methods.In some countries, mostly in Africa, the first wave of the pandemic was less severe in comparison to other countries, and in-person services were allowed to resume while abiding by the imposed regulations.Furthermore, when COVID-19 restrictions were eased as the first wave of the pandemic was becoming less severe, in-person services were resumed gradually.
Several of the adaptations were influenced by the decision of organisations to prioritise services for the most vulnerable adolescents either by developing inclusive services or ones that were specifically tailored to these groups.In addition, a few organisations noted that they tried to specifically reach adolescents living in remote rural areas, informal urban areas, or other disadvantaged communities due to the anticipated impact of the pandemic on underserved groups of adolescents.They used remote or digital services, based on the context and adolescents' preferences.Finally, many of the organisations added mental health services to their packages due to the anticipated burden laid on adolescents by the COVID-19 pandemic.These reasons † According to UNESCO, Comprehensive sexuality education (CSE) is "a curriculum-based process of teaching and learning about the cognitive, emotional, physical, and social aspects of sexuality.It aims to equip children and young people with knowledge, skills, attitudes, and values that will empower them to: realize their health, well-being, and dignity; develop respectful social and sexual relationships; consider how their choices affect their own well-being and that of others; and understand and ensure the protection of their rights throughout their lives". 26In different countries, these curricula or programmes may be adapted and referred to with different names.Most of the organisations reported that they consulted with one or more groups of adolescent target users, service providers, partners, and other key informants to develop their adaptations.
Part of the adaptations that were developed in consultation with adolescents, was with adolescent volunteers or target audiences.For example, in Fiji, youth volunteers were involved in linking the organisation with adolescents and young people in their communities to learn about their needs and preferences, which influenced the design and planning of the outreach components used during the pandemic.In Namibia, the organisation based its SRH education activities on using online messaging services.However, when they consulted adolescents, they learned that it was costly and required an internet subscription; thus they reverted to peer-to-peer learning while enacting COVID-19 protective measures.In Argentina, the government conducted interviews with adolescent users to assess the barriers to access to services, the impact of COVID-19 on the most vulnerable groups, and the feasibility of proposed options.Based on these discussions, it prioritised the delivery of SGBV care and providing contraceptives in neighbourhoods that are far from the delivery centres.In addition, it provided the needed devices to several facilities to enable them to deliver telehealth consultations.On top of that, they utilised radio and television to disseminate SRH information to areas that lacked access to internet services.Finally, in different countries, when lockdown measures eased, and in-person services were resumed, many organisations maintained remote and digital services due to the preference of adolescent clients.

Delivery and implementation of adaptations to SRH programmes
Many of the organisations were able to adapt their consultations and counselling services provided at healthcare facilities during the lockdown by abiding by COVID-19 guidelines and employing protective measures, using personal protective equipment (PPE), maintaining social distancing, having shorter consultation durations, and limiting the number of beneficiaries in waiting areas.Washing stations, sanitisers, soap, and masks were made available to the visitors, and appointment scheduling was used to avoid crowdedness.When transportation was restricted by government-mandated curfews, a few organisations were able to get exemptions for the mobility of their staff or adolescents accessing SRH services.When public transportation was limited, some organisations arranged for specific transportation for adolescents to be able to visit healthcare facilities.On the other hand, when adolescents did not prefer to have in-person contact, or no in-person services were running due to COVID-19-related mandated shutdowns, other approaches were used, such as telemedicine, phone calls, or What-sApp calls, to communicate with service providers.In one of the case studies, dispensaries were used to provide condoms, and in two others, e-Pharmacies were used to allow adolescents to order SRH commodities.In areas where it was difficult for adolescents to reach healthcare facilities or did not have access to mobile phones or the internet, outreach teams were deployed to their communities, and healthcare providers distributed SRH commodities and provided consultations, counselling, and support through their mobile clinics or by conducting at-home visits.When it was not possible for organisations to resume their in-person services, they referred adolescents to other sites.This required the organisations to map available services to refer adolescents to a functioning healthcare service.Organisations resorted to digital-based approaches to provide SRH information using websites, short messaging services (SMS), social media, and mHealth apps.Some organisations used social media platforms and apps such as Facebook, Zoom, and WhatsApp groups to carry out SRH education sessions.Furthermore, organisations adapted the way they promote the availability of services, whether it was through mass messaging with SMS, social media channels, and calls.Another approach was assisting adolescents in scheduling their appointments and coordinating their visits by providing adolescents with a WhatsApp to help with the scheduling of appointments and visits to the operating clinics.
In a few of the case studies, organisations either provided small incentives to adolescents to cover the cost of access to the internet, used social media apps that are available within the basic internet bundles, or included offline versions of their features.Other organisations tended to adolescents who may not have access to the internet or smartphones by using radio and television for edutainment programmes.As for services that were housed in the schools before the pandemic, they were mostly provided remotely.A few of the schools were able to resume their SRH education activities in small groups while employing COVID-19 protective measures when the lockdown measures were eased by their respective governments.Details of the adaptations used by the organisations appear in Table 2.
In the following section, we provide an overview of the different adaptations used to provide adolescents with SRH programmes and mental health services.

Adaptations to SRH programmes SRH education
Most organisations shifted to providing SRH education programmes using remote options, mostly with digital modalities.Organisations primarily used Facebook pages for asynchronous activities or WhatsApp for both synchronous sessions and asynchronous access to information.WhatsApp was used for carrying out sessions using WhatsApp group video calls, sharing educational audio and video messages and social media posts, and having a dedicated space where SRH educators could engage with young people and respond to their queries, whether individually or as a group.In addition, virtual meeting apps such as Zoom and Google Meet were commonly used for conducting online sessions and holding SRH talks or discussions with adolescents.Furthermore, organisations used websites or mobile apps to disseminate SRH information.For instance, Safeguard Young People (SYP) provided adolescents with information about reproductive health, including menstrual health, and gender-based violence on their "TuneMe" website, which was provided as part of the basic Internet bundle without any additional charges.Moreover, OneWorld Benin used its mobile app to provide SRH information to adolescents in a confidential manner.In addition to the digital tools, six organisations utilised radio broadcasting to remotely provide SRH information through dialogues, structured lessons, and edutainment programmes.In Myanmar, BBC Media Action supported the development of radio and digital content for adolescents with disabilities.Furthermore, Love Mater India's radio weekly episodes provided adolescents with SRH information after the onset of the pandemic.On the other hand, some of the organisations were able to continue their in-person SRH education activities with some modifications.In Myanmar and India, organisations continued their face-toface group sessions, but with reduced sizes to better observe social distancing measures.
Five organisations used alternative means to resume their CSE activities.These adaptations included the use of asynchronous online learning modules and synchronous online group sessions, in addition to social media and messaging apps.In India, a seven-module CSE programme was delivered via online sessions to both in-school and out-of-school adolescents.In the Philippines, online sessions were complemented by virtual groups and hotline services.In Zimbabwe, the Ministry of Education had the teachers adapt the CSE programme to reach adolescents through radio edutainment lessons.In Myanmar and Namibia, in-person activities were adapted to comply with COVID-19 prevention protocols.
Moreover, messaging apps were also used to provide SRH information snippets that were adapted from the CSE curriculum.

Contraception services
Seven organisations from the DRC, India, Myanmar, Uganda, Namibia, Fiji, and Nigeria provided contraceptives in their clinics that operated in line with COVID-19 safety guidelines, with social distancing, use of masks, spacing between appointments, and operating in shifts convenient for clients.Two organisations, from the DRC and India, installed condom dispensers and boxes in accessible locations in health facilities for a "quick grab and go".Additionally, one organisation set up kiosks that were installed near the outpatient departments of hospitals and were operated by female health workers.On the other hand, multiple organisations used outreach activities, mobile clinics, or household visits to provide contraceptives.For instance, two organisations from the DRC and the Philippines distributed contraceptives door-to-door.In Nigeria, contraceptives were provided upon request during household visits.Moreover, in Fiji and India, mobile clinics provided contraceptives, counselling, and referrals.In addition to providing contraceptives, four organisations provided contraception-related counselling services, either at their clinics, by outreach teams, or remotely through online or tele-counselling.

Abortion and post-abortion care
Three case studies were specific to abortion and post-abortion care.In Argentina, the Directorate of Adolescents and Youth and the Ministry of Health established a coordinated response to SRH issues through an intersectoral network of partners that covered the education, justice, and social development sectors.This network was able to refer requests for abortions from adolescents to the concerned service providers.Furthermore, they developed telehealth services guidelines and were able to provide remote consultations and counselling by phone or using telehealth arrangements.In the Philippines, one organisation assigned a hotline specifically for post-abortion care referrals, and provided postabortion care in its clinics while complying with the COVID-19 safety protocols.Similarly, in India, health facilities of one organisation provided abortion and post-abortion care that was modified according to COVID-19 precautions.This was complemented by a community outreach component to promote the availability of the services and assist in the scheduling of appointments.Furthermore, it arranged for transportation using their ambulances to circumvent the mobility restrictions imposed by the lockdown.

Menstrual health
In India, Myanmar, and Nigeria, organisations distributed sanitary napkins or pads to adolescent girls at home.Among those, some prioritised adolescent girls with greater needs, such as those living in shelters, those with disabilities, and those living in poor households.Furthermore, they distributed other items such as face masks, sanitisers, and soaps, as well as iron-folic acid tablets and food packages.
In Nigeria, social media and radio edutainment programmes were used to provide information about menstrual health to adolescents.In Nepal, information was shared through online platforms and included lessons on how to make reusable sanitary napkins at home during the lockdown.In India, menstrual health education sessions were conducted with adolescent girls and boys via WhatsApp, and virtual activities such as poetry and mobile phone film-making competitions took place to engage adolescents and provide them with information.

SGBV care
Multiple case studies provided examples of adaptations to SGBV care.In Argentina, remote consultations and counselling were provided by phone or using telehealth arrangements when requested.In the Philippines, one organisation developed a Facebook-based platform to create a virtual community for adolescents where professionals respond to their SGBV concerns.In addition, it provided SGBV counselling and mental health support in its clinics and set up a hotline for SGBV care referrals.In Nigeria, the Stand With A Girl created a virtual safe space using What-sApp groups to discuss SRH topics with adolescent girls, with a particular focus on SGBV, and the Stand To End Rape Initiative (STER) used phone services to support those who experienced SGBV and linked them to appropriate service providers.They provided mental health counselling via Zoom and Skype or used text messages for adolescents who preferred that option for communication.In addition, they arranged for transportation and facilitated the scheduling of services when needed.

Care for adolescents living with HIV
Four case studies provided responses that were particular to adolescents living with HIV.From Zimbabwe, Africaid and the Ministry of Health and Child Care, through the Zvandiri Programme, established a virtual case management system for adolescents living with HIV, built virtual support groups, provided virtual clinical and psychosocial HIV services, and shared reminders via their app to follow-up on adherence to treatment.Furthermore, their community adolescent treatment supporters initiated outreach visits, where they distributed ARTs, facilitated the measurement of the viral load, and provided the needed counselling and support.In India, online psychosocial support and tele-counselling were used to promote adherence to the ARTs.In the Philippines, HIV testing kits were distributed to adolescents.Finally, in Kenya, the University of Nairobi established virtual groups, through Zoom and Skype, to provide self-care, psychological first aid, and referral services, primarily for pregnant adolescents and adolescent parents living with HIV.In addition, they distributed ARTs door-to-door.

HPV vaccination
One case study reported on an adaptation to the national HPV vaccination programme In Laos.The vaccination programme was halted because of the closure of schools.The Ministry of Health shifted the programme setting to health centres and added mobile clinics in hard-to-reach sites.They sent messages through various channels to reach communities, parents, and girls and encouraged all eligible girls to visit the nearest centre or mobile clinic to receive the HPV vaccines.

Distribution of SRH commodities
In two case studies from Uganda, UNFPA partnered with two for-profit organisations that provided app-based services.One of them was the e-Shop app, Jumia, which before this partnership did not provide a youth-centred SRH service.The other was SafeBoda, a motorcycle taxi app providing access to safe transportation.Both Ugandan organisations developed an e-Pharmacy section that could be accessed by adolescents to purchase SRH commodities and have them delivered with privacy and confidentiality, without additional delivery costs.Jumia increased its existing SRH products' inventory, and SafeBoda onboarded ten major pharmacies to allow for the online ordering of SRH commodities.This allowed adolescents to order a range of commodities that included HIV testing kits, pregnancy testing kits, condoms, and menstrual health products, among others.Furthermore, with the support of UNFPA, Jumia had its customer service staff trained on SRH topics and provided information for their clients.On the other hand, Safeboda drivers delivered condoms to community health workers, peer educators, and village health teams to distribute them free of charge in their respective communities.

Adaptations to mental health services
Many organisations, unprompted by WHO, included information about mental health services that they provided to adolescents during the pandemic, either as a complementary component of particular SRH services, such as HIV, SGBV, and abortion care, or as standalone services.For example, in India and Kenya, online counselling and psychosocial support were provided to adolescents living with HIV.In Zimbabwe, home visits with care teams provided adolescents with counselling and support.In Nigeria, mental health education, counselling, and psychosocial support were provided using a range of delivery mechanisms, such as phone services, virtual meeting apps, and text messaging.In Zimbabwe, call centres were used to refer those in need to appropriate services.Additionally, in Namibia, mental health support was provided through door-todoor outreach and mobile clinics.

Monitoring of and follow-up on adaptations to SRH programmes
Organisations reported using a variety of methods and indicators to monitor their activities.The information was gathered through surveys, social media metrics, tracking sheets for service utilisation and commodities distributed, case management data, and feedback from users, healthcare providers, and staff across the different platforms.In-person data collection was impacted by the pandemic in most cases.Therefore, follow-up channels included phones, social media, virtual meeting apps, and messaging apps.In some cases, small group meetings took place to follow up on ongoing activities.Some unique examples provided real-time information for follow-up and monitoring of the adapted SRH services.For instance, e-Pharmacies provided real-time information about the number of clients and the number of SRH commodities that were purchased and delivered.Furthermore, the Zvandiri programme had its mobile app (ZVAMODA) for case management that was able to provide real-time data for follow-up on adolescents living with HIV registered on the app.They were able to track their HIV care needs and preferences and follow-up on their treatments and their adherence.
The most used indicators were "reach" and "utilisation" measures.For example, organisations measured the reach of and engagement with their social media and online resources, which included the number of views of webpages or social media posts, the number of unique online visitors, the number of resources downloaded, and the number of participants in their online sessions.Service utilisation measures included the number of adolescents who were provided with counselling, consultations, and commodities, in addition to the number of referrals through hotlines, messaging apps, or outreach activities.
Less than half of the organisations provided specific data at the time of collecting these case studies, although they mentioned the methods they were using or intended to use for data collection and follow-up.Among those that provided specific information, a few did not provide adolescent-specific data.The information shared by the organisations reported positively about the reach and coverage of their adapted services and the satisfaction of adolescent users.A summary of data provided in the case studies can be found in Table 3.At the time of this study, it was not possible to obtain information about the evaluation of these programmes.

Discussion
This study set out to explore how organisations adapted their services to respond to the SRH needs of adolescents during the early phase of the COVID-19 pandemic.We gathered, analysed, and synthesised lessons learned from 36 case studies about the adaptations to service provision by 41 organisations from 16 LMICs, that provided SRH information and services to adolescents.The case studies covered face-to-face, remote, digital, and non-digital adaptations that were used to provide a wide range of SRH and mental health services, to different groups of adolescents.They provide useful lessons in terms of their development, implementation, and follow-up.
Our analysis showed that these adaptations covered a wide array of SRH services, mostly SRH education and access to contraception services.In addition, the study included examples of adaptations to services related to HIV care, menstrual health care, safe abortion and post-abortion care, SGBV care, distribution of SRH commodities, and a unique case study about adaptations used to provide HPV vaccination to adolescents.The case studies targeted a diverse group of adolescent groups, mostly adolescent girls, adolescent school students, or adolescents in nearby communities.A few of these efforts targeted other groups, including vulnerable adolescents, such as out-of-school adolescents, adolescents living with HIV, pregnant, parenting, or married adolescents, adolescents living in rural or urban informal settings, adolescents with disabilities, and LGBTQ+ adolescents.These examples showed that it was possible to adapt a range of SRH services in different contexts to reach adolescents, including those who are especially vulnerable, after the start of the pandemic.Furthermore, one of the positive findings is that adolescents' mental health was prioritised by many organisations that provided them with mental health services either as a component of the SRH services or as a standalone component.Organisations cited the exacerbation in the burden on adolescents' mental health due to the pandemic, as reported by multiple studies, 13,27 as a reason for including mental health services as part of their adaptations.
The study provided insights regarding the development, implementation, and monitoring of adaptations to SRH services for adolescents.Firstly, many organisations developed their adaptations to SRH services as a direct response to the impact that lockdown measures, services' closures, and mobility restrictions had on limiting or interrupting the access of adolescents to SRH services during the early stages of the COVID-19 pandemic. 8Furthermore, they developed their adaptations to reach underserved or vulnerable adolescents to mitigate the impact of the COVID-19 pandemic on these groups. 15As the adaptations were meant to circumvent the previously stated barriers resulting from the pandemic or the responses to it, they developed one or more adaptations to resume SRH services in health facilities and schools, implemented outreach activities to reach adolescents in their communities, referred them to other functioning SRH services when services were shut down, and used digital-and remote-based services when inperson static services were not possible or were not the option preferred by the adolescents.It is worth noting that some of the case studies provided examples of adaptations developed in consultations with adolescents, whether they were adolescents who contributed to service delivery or were part of the intended target audience.Consulting adolescents may have increased the chances of providing them with services that responded to their needs and preferences while taking into consideration factors such as the availability of transportation, cost of the internet, digital literacy, or access to smartphones, among other factors, in line with what has been reported elsewhere. 8Therefore, they arranged for transportation for adolescents, provided small incentives for internet use, or used low-cost approaches that used basic internet bundles, enabled costfree access to offline versions of their approaches, and implemented outreach activities for those who did not have regular access to the internet and had limited mobility.
Secondly, in terms of the delivery and implementation of the adapted services, when service closure was not mandated or when COVID-19 restrictions were eased, in-person services were provided.Organisations modified their services in line with required COVID-19 safety measures by using PPE, maintaining social distancing, scheduling appointments, and spacing between these appointments.As a result, many organisations maintained their on-site services, but some of them also used remote approaches such as outreach teams, mobile clinics, community health workers, or young peers to provide SRH education, services, commodities, and referrals.There were a few examples of the provision of remote services using relatively innovative approaches, such as condom dispensers, e-Pharmacies, and no-contact delivery of SRH commodities, and radio and online SRH edutainment programmes.In addition, many organisations used helplines to provide counselling and referrals and to assist in the scheduling of appointments.Most remote services relied on digital adaptations, such as the use of social media, SMS, mobile apps, e-Pharmacy apps, virtual meeting apps, and online websites to provide SRH education or counselling, and assist in referrals, scheduling of appointments, and advertising for in-person services that were being resumed in the different clinics.Among the organisations that used digital adaptations in their SRH services, most used more than one modality of the previously mentioned adaptations.Additionally, most of the adaptations were simple rather than a complete revision of SRH programmes, in line with the objective of nimbly and quickly responding to the needs of adolescents in the early phase of the pandemic.As reported by Malkin and colleagues, simple and measured adaptations to existing services could be of promising value in terms of reaching adolescents and providing them with services with the needed urgency. 28oreover, a considerable number of organisations used a combination of digital and face-to-face adaptations to the SRH services to achieve a synergetic effect.Even the organisations that relied on digital-based interventions at the beginning of the pandemic reported shifting their adaptations when the lockdown measures were eased to include more in-person components.Many organisations opted to provide in-person services in addition to their remote and digital-based services to maintain the preferred mode of delivery of SRH services by adolescent users or to ensure continuity of services as they were entering the second wave of the pandemic.According to a study in the Philippines, the use of both modalities -physical and virtual -to provide consultations and counselling to adolescents led to higher levels of utilisation by adolescents and young people when compared to using only one method. 22inally, in terms of monitoring and follow-up, organisations resorted to the use of phones, social media, SMS, and virtual meeting apps to follow up on their operations and communicate with their teams.Most organisations provided information about the tools used for monitoring and followup.While less than half provided relevant data, the organisations that shared their information reported positively about the reach and coverage of their adapted services or the satisfaction of adolescent users.Still, this should raise concerns about the importance of monitoring and then evaluating these adaptations.
To put our study in context, we compare it to a number of examples of adaptations that were documented in the literature.Some examples described adaptations to in-person services, whether they were carried out in health facilities and schools or through outreach activities.In Brazil and Zimbabwe, social distance measures and infection control measures were observed in health facilities and included mandating social distancing, mask-wearing, providing PPE for health providers, providing some services outdoors, and installing handwashing facilities. 21,29In Indonesia, a teacher-led school-based CSE programme continued in classes -in some schools -with reduced student capacity and observing social distancing measures. 30As for outreach activities, there is an example from Kenya, where youth community health volunteers were mobilised in their communities to reach young adolescents and provide them with SRH information, counselling, and commodities such as condoms and contraceptive pills. 28imilar to our study, while in-person activities had their value in providing adolescents with face-to-face support, 21,31 it was important during the early phase of the pandemic to provide alternative options for adolescents for whom access was difficult and to respond to their preferences in terms of the approach used to deliver the service.For instance, in India and Brazil, telemedicine was used to provide family planning counselling 32 and HIV care 29 to adolescent girls and adolescents living with HIV, respectively.As for SRH education, in-person SRH education lessons were digitised and disseminated to adolescent girls through WhatsApp in Nigeria, 28 and social media were utilised to provide HIV prevention information to adolescents in Zambia. 33These examples document different adaptations to SRH education, in addition to contraception services and HIV care, with similar strategies to the ones reported in our case studies.Yet, our set of case studies could be of added value to the base of evidence as it contains information about adaptations to a wider range of SRH services that includes safe abortion and post-abortion care, SGBV care, HPV vaccination, and examples of the distribution of a variety of SRH commodities, in addition to mental health services, that were provided to diverse groups of adolescents, sometimes using different approaches, concurrently, to provide different services and increase their reach.

Study implications
Our study findings show that organisations in the LMICs nimbly adapted a wide array of SRH services that were provided to different groups of adolescents in different contexts, using multiple modalities, including physical and remote services, with digital and non-digital adaptations, sometimes as standalone adaptations and at other times in combination, to reach the different groups of adolescents, and ensure continuity of services.In addition, the study has shown that mental health issues were prioritised while addressing SRH services; this could well provide an opportunity for exploring future linkages between mental health and SRH programming for adolescents.Furthermore, the study pointed to lessons learned from adapting SRH services according to the context of the early phase of the pandemic, the level of severity of the first wave, the extent of lockdown measures, and governments' responses.In addition, in some instances, adaptations benefited from the involvement of adolescents in the design and implementation of these adaptations, as their input facilitated reaching the best iterations of these adaptations to enhance chances of reaching adolescents and responding to their SRH needs.
Some of these modalities were in use prior to the pandemic, 34,35 yet these case studies show that there has been a clear expansion in using the different adaptations, including digital adaptations, during the pandemic.Further, information provided on such adaptations gives an insight into their perceived benefits, despite the extenuating circumstances in which they were developed and implemented.Rigorous evaluations are needed to determine if these adaptations could influence adolescent SRH outcomes in the long term.For instance, in Zambia, a study reported that a combination of in-person and digital adaptations to HIV testing services was safe, feasible, and resulted in more uptake of HIV testing services among adolescents. 33On the other hand, in Zimbabwe, a study reported that some of the adaptations used to provide SRH services had a negative impact on reaching adolescents, their retention, and the acceptability of the adapted services, as core elements of the services were not optimally adapted, which affected the quality of services delivered by the healthcare providers. 21Therefore, careful evaluation of these adaptations should be considered, particularly for longer-term outcomes.
While WHO has declared that the COVID-19 pandemic is no longer a public health emergency, 36 lessons learned from this study can feed into discussions about the positioning of these adaptations into preparedness programmes to mitigate the impact of future public health emergencies on adolescents' access to SRH services.It could be harder to apply the lessons learned in areas of humanitarian crises resulting from conflict or natural disasters where infrastructure is Therefore, it is important to take into account the context when considering the set of adaptations presented in our study.Future research could explore if these adaptations were utilised in the following waves of the pandemic, particularly when COVID-19 vaccinations started to roll out the following year, albeit in some countries more than others, 37,38 or in the post-pandemic era, and if that is informed by implementation evidence, as it could draw lessons on how these adaptations could be situated in current ASRH programming.

Limitations
The study has a few limitations.Firstly, most of the case studies came from Africa and Asia.While the call had no geographical restrictions and all regional offices were approached, responses came mainly from these regions.This reaffirms the opportunistic nature of the study, and while Africa and Asia constitute the places where most adolescents are currently living globally, 39 the study could have benefited from better representation.Secondly, only a few of the case studies targeted some of the most vulnerable groups of adolescents.Some adolescent groups, such as LGBTQ+ adolescents, adolescents living with disabilities, adolescents living in rural or informal urban areas, and pregnant adolescents or adolescent mothers, were not highlighted in enough depth in this study.In the future, targeted research should be carried out to learn about how programme adaptations could respond to the special needs of these groups to ensure that they are not left behind.Thirdly, there were some issues with the quality of data and information reported by the organisations.While the information provides insights in terms of the potential feasibility and acceptability of the adaptations made, as reported by some of the organisations, it is crucial to point out that these results were not validated or verified.In the future, rigorous evaluation is needed to best attain a picture of the effectiveness of those interventions in achieving favourable results for longterm ASRH outcomes among adolescents.Finally, the findings of the study are particular to the early phase of the pandemic, particularly during or after its first wave, and with no additional information, it is important not to extrapolate the findings to the entirety of the pandemic, where different regulations were imposed, or COVID-19 vaccination may have rolled out.It is important to consider the context of these adaptations as rapid and nimble responses by the organisations that may have changed with time.

Conclusion
The study showed that organisations operating in different countries and contexts were able to provide SRH and mental health services to adolescents despite the extenuating circumstances prevailing in the early phase of the COVID-19 pandemic.These adaptations were reported to be doable by programmers and acceptable to the targeted adolescents.Simple adaptations to existing programmes, the use of combinations of digital and non-digital services, and the involvement of adolescents in the design and implementation of these adaptations helped facilitate these adaptations.Lessons learned from this study could be extrapolated into future public health emergencies, but future research should curate rigorous evaluations to assess the effectiveness of these UNFPA and SafeBoda -Uganda • Provided 815,325 people with information on SRH through various SafeBoda communication platforms, including social media, since its launch in June 2020 • Distributed 1,175,040 free condoms in communities around Kampala city • On the online Personal Health Pharmacy, 3075 orders were made on the app, and 4720 items were delivered Youth in Action (Y-ACT) -Kenya • Provided 8725 women and girls with sanitary pads adaptations in achieving favourable results for long-term SRH outcomes among adolescents and focus on reaching the most vulnerable.

Table 2 . Adaptations to adolescent SRH services during the COVID-19 pandemic Organisation Adaptations Target audience Innovative actions Monitoring and follow-up
• Community Adolescent Treatment Supporters (CATS) conducted follow-up home visits, distributed ARTs and provided counselling and support and measurement of viral load• CATS provided reminders via the Zvandiri Mobile Database Application (ZVAMODA) for adherence to treatment• Provided contraceptives to young people through their clinics while maintaining COVID-19 safety protocols• Installed mechanical dispensers to provide condoms without human interaction and added masks and gloves next to the dispensers • Disseminated a WhatsApp number to coordinate young people's requests for information, access to certain contraceptives, and scheduling of appointments Community outreach • Assigned young people as focal points and contraceptive suppliers who distributed contraceptives -door to door-to adolescents and young people in their neighbourhoods • Supported the development of radio and digital content by Myanmar Independent Living Initiative (MILI) for adolescents with disabilities • Carried out ASRH education activities through social media using interactive quizzes and personalised messages and provided responses to queries and updated their Facebook page ASRH content using motion graphics and animations • Shared information to adolescent girls via digital platforms about menstrual health (MH) and how to make reusable napkins at home during the lockdown Service promotion, delivery and referrals • Distributed menstrual products and food packages • Set up a 24-hour toll-free number -in collaboration with partner organisations-to provide counselling services by doctors and midwives on safe motherhood and reproductive health • Promoted and referred adolescents to services available by the government and partner organisations, such as SGBV hotline and psychosocial counselling and support services • Adapted their Integrated Multi-Sectoral Approach (IMSA) programme in schools to be add an online ASRH earning component via Zoom, Google Meet, and Facebook messenger • Continued in-person group ASRH education sessions, in small groups to engage parents and guardians, teachers, and young people Community outreach • Continued to distribute commodities such as: menstrual hygiene kits, face masks, food packages, among others • Peer educators disseminated ASRH and COVID-19 information via ten video and audio messages distributed via social media and WhatsApp Community outreach • Distributed sanitary napkins, and folic acid tablets and referred adolescents to available services such as counselling hotlines • Provided SRH messages to adolescents through social media, phone calls, and local radio Service delivery and referrals • Established an intersectoral network of partners that covered sectors such as education, justice, social development, and other local institutions for coordinated responses • Provided virtual counselling, phone consultations and teleconsultationsafter developing appropriate guidelines, to adolescents • Referred cases of suspected sexual abuse, suicide attempts, domestic or gender-based violence, and requests for abortion counselling and services, to rights protection agencies, territorial focal teams and other agencies A K Ali et al.Sexual and Reproductive Health Matters 2024;32(1):1-30• Provided adolescents with teleconsultations through Zoom and WhatsApp about SRH and COVID-19-related issues ASRH education • Adapted the delivery of their CSE programme to an online mode • Engaged with students through social medial and carried out virtual activities and competitions such as a poetry competition on menstruation and a mobile phone film-making competition • Maintained online CSE sessions and shared messages on SRH via social media Service delivery and referrals • Launched the YouRHotline, a Facebook-based platform to create a virtual community and safe space for adolescents where professionals respond to young people on their SRH (including SV and IPV) and mental health queries and concerns • Set up additional hotlines for post-abortion care, and SGBV referrals • Referred adolescents in need to their clinics, and when needed, their partners • Offered counselling and psychological services as part of SGBV care Community outreach • Delivered SRH commodities door to door such as HIV-and pregnancytesting tests, and contraceptives • When implants were requested, a nurse or a midwives took on the visit * Innovations that did not take on a digital form.** At the time of conducting this study.